Advocacy Efforts

The ABA Coding Coalition advocates for policies and practices to ensure that billing codes for ABA services are implemented as intended by the code authors and in accordance with professional standards of care. Our main advocacy activities are described here.

Members of the ABACC have been working with the Centers for Medicare and Medicaid Services (CMS) to establish appropriate medically unlikely edits (MUEs) for billing codes for adaptive behavior services. An MUE is the maximum number of units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.  MUEs are set by an agency contracted by CMS called the National Correct Coding Initiative (NCCI), and are intended to reduce the paid claims error rate for Medicare claims. Although third-party payers are not required to follow the MUEs established by CMS, many incorporate them in their claims processing systems and policies.

When the MUEs for the 2019 CPT® codes for adaptive behavior services were released in December 2018, the former steering committee for ABA services (described in the “About Us” section) asked CMS to revise several of the proposed MUEs. CMS agreed to most of those requests, but for code 97151, CMS changed the Medicaid MUE to 32 units (8 hours) per day and left the Medicare MUE for that code at 8 units (2 hours). CMS publishes only the Medicare MUEs on its website, and many payers use the Medicare MUEs. A copy of the December 13, 2018 letter from NCCI is available here. The table that follows represents the Medicare MUEs that were released July 1, 2019, which can also be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2018 American Medical Association. All rights reserved.

CPT® is a registered trademark of the American Medical Association.

Applicable FARS\DFARS Restrictions Apply to Government Use.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein.

HCPCS/
CPT Code
Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale
97151 8 3 Date of Service Edit: Clinical Clinical: CMS Workgroup
97152 8 3 Date of Service Edit: Clinical Clinical: CMS Workgroup
97153 32 3 Date of Service Edit: Clinical Clinical: Society Comment
97154 12 3 Date of Service Edit: Clinical Clinical: CMS Workgroup
97155 24 3 Date of Service Edit: Clinical Clinical: Society Comment
97156 16 3 Date of Service Edit: Clinical Clinical: CMS Workgroup
97157 16 3 Date of Service Edit: Clinical Clinical: CMS Workgroup
97158 16 3 Date of Service Edit: Clinical Clinical: CMS Workgroup
0362T 8 3 Date of Service Edit: Clinical Nature of Service/Procedure
0373T 24 3 Date of Service Edit: Clinical Clinical: Society Comment

The ABACC submitted requests to CMS for additional changes in MUEs for the adaptive behavior services codes, specifically to make the Medicare MUE for code 97151 the same as the Medicaid MUE and to increase MUEs for codes 97154 and 97155. The CMS responded that because the code set is new, they declined to make further changes in the MUEs until more data on typical utilization of the codes are available. The ABACC plans to collect information from providers to support future requests for modifications in MUEs. Updates and additional resources on MUEs will be posted on this website; ABACC member organizations will also apprise their constituents via email and social media. Providers who wish to appeal denied claims based on MUEs should visit the CMS website for guidance, and be prepared to include in their appeal rationale and evidence that daily service units higher than the MUE are medically necessary for the client in question.

Autism Law Summit (October 2019)

Members of the ABA Coding Coalition participated in the annual Autism Law Summit in October 2019 in Jackson Hole, Wyoming. The Autism Law Summit is an annual national gathering of autism parents, providers, professionals, lawyers, legislators, researchers, and others interested in the policy and politics of autism. Participants share information about how best to utilize existing laws and regulations for the benefit of individuals with autism; attendees also brainstorm needed legal reforms and strategize about how to achieve such change. For more information, visit www.autismlawsummit.com.

Of particular note, members of the ABA Coding Coalition helped lead an interactive Payer Workshop that took place the day before the Summit. The Payer Workshop brought together national and regional insurance and Medicaid payers who are actively engaged in managing the payment of ABA claims with providers and billers who submit such claims. The Payer Workshop fostered open conversation and collaborative problem-solving on CPT® coding issues and other payment matters.

Conference Presentations and Webinars

ABACC members have given presentations on the 2019 codes for adaptive behavior services and related topics at numerous state, regional, and national conferences as well as webinars hosted by several organizations. To request a presentation for providers, payers, or other interested parties, please contact the relevant Coalition member organization or the consultant directly, or use the Contact feature on this website.

The former steering committee described in the About Us section sent its Supplemental Guidance article on the 2019 CPT® codes to 20 national payers. Providers are encouraged to use it and share it with their payers. Subsequently the ABACC has provided feedback and consultation to several payers on their implementation of the 2019 code set via letters, phone conversations, and emails, and will continue to do so as appropriate. Additionally, with the help of an experienced ABA health insurance biller, the ABACC is attempting to track payer implementation of the 2019 CPT®codes. That information, which will be updated as new information becomes available, is in the Payer Implementation Tracker document on our Resources webpage. Members of the Association of Professional Behavior Analysts can also access it and associated resources by logging in to www.apbahome.net, then going to Members Only > Health Insurance Coverage.